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A review published by Public Health England (PHE) has found that more than 500,000 patients in England were continuously prescribed an opioid for three years or more, despite a lack of evidence showing their efficacy in the long term.
The review, which was published on 10 September 2019, is the first to investigate dependence and withdrawal problems associated with five commonly prescribed types of medicines in England: benzodiazepines, Z-drugs, gabapentinoids, opioids and antidepressants. It found that one in four (11.5 million) adults in England were prescribed at least one of these types of medicines in the year ending March 2018.
Half of these had been continuously prescribed the medicine for at least the previous year, and between 22% and 32%, depending on the type of drug, had received a continuous prescription for at least the previous three years.
The review said that, of these patients, “approximately 540,000 had been prescribed opioids coninously for 36 months or more”, despite evidence that “prescribing opioid pain medicines for longer than 90 days was associated with opioid overdose and dependence”.
“Long-term prescribing of opioids for chronic, non-cancer pain is not effective for most patients and guidelines specify that benzodiazepines should not usually be used for longer than 2 to 4 weeks,” it continued, while adding that, for some medicines, such as antidepressants, long-term prescribing may be clinically appropriate.
The review also found that following years of increase prior to 2016, prescriptions for opioids and Z-drugs decreased in 2016/2017 and again in 2017/2018.
For antidepressants and gabapentinoids, however, the prescribing rate increased between 2015 and 2018. This was most marked for gabapentinoids, which had a 19% increase in the number of prescriptions, from 1.2 million to 1.5 million.
Prescribing rates and duration of prescription were higher in some of the most deprived areas of England, the review noted. For example, prescribing of opioids and gabapentinoids was 1.6 times higher in the most deprived areas, compared with the least deprived.
Claire Anderson, chair of the English Pharmacy Board at the Royal Pharmaceutical Society, said it was “incredibly important” that the prescribing guidelines for these medicines are followed and that patients taking them are monitored closely.
“As the role of pharmacists, including as prescribers, grows across the NHS, they have an increasingly important role to play in discussing and reviewing medicines with patients,” she said.
“Patients with pain, mental health issues and anxiety want to be free of [these things] and often the long-term answer for these conditions doesn’t lie in the prescription pad,” she added.
“Reducing prescribing may be appropriate, but must be combined with access to other services, such as talking therapies, mental health support and social prescribing.”
PHE’s review recommends better monitoring, treatment and support for patients, including giving NHS commissioners and doctors better access to data to improve insight of prescribing behaviour; updating clinical guidance for medicines which can cause problems with dependence and withdrawal; improving training for clinicians; and giving better information to patients about the benefits and risks associated with these medicines.
It also recommended that a national helpline is set up to provide patients with a combination of support and guidance on topics, such as tapering and coping with withdrawal symptoms.
Keith Ridge, chief pharmaceutical officer at NHS England, said: “These medicines have many vital clinical uses and can make a big difference to people’s quality of life. And, for some, their long-term use is clinically necessary — particularly antidepressants — which can take longer to have their full effect.”
“But for many patients, they may not be the best option, with talking therapies and social prescribing often [being] more appropriate.”
Sheuli Porkess, executive director of research, medical and innovation at the Association of the British Pharmaceutical Industry, said that pharmaceutical companies were “fully committed” to playing their part.
“We’re working with [the Medicines and Healthcare products Regulatory Agency], PHE and other professional bodies to help make sure that all medicines are prescribed and used safely and appropriately.”
The National Institute for Health and Care Excellence (NICE) is currently developing a guideline on the safe prescribing and withdrawal of prescribed drugs.
Paul Chrisp, director of the Centre for Guidelines at NICE, said: “The proposed scope of this guideline should complement the evidence review. We are consulting on the proposed scope until the end of the month.”
